Healthcare Provider Details

I. General information

NPI: 1295746691
Provider Name (Legal Business Name): TRISTATE ORTHOPAEDIC TREATMENT CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 05/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10547 MONTGOMERY ROAD SUITE 400
CINCINNATI OH
45242-4418
US

IV. Provider business mailing address

10547 MONTGOMERY ROAD SUITE 400
CINCINNATI OH
45242-4418
US

V. Phone/Fax

Practice location:
  • Phone: 513-791-6611
  • Fax: 513-791-6788
Mailing address:
  • Phone: 513-791-6611
  • Fax: 513-791-6788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CLYDE E HENDERSON JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 513-791-6611